E/M Coding Basics for Internal Medicine

Evaluation and management is the most important part of the practice for an internist and coding for these visits can have an important effect on the bottom line of a practice. The decision about what level to bill an evaluation and management code is rarely clear to most physicians. In order to determine what code to select for an evaluation and management procedure, it helps to first learn the elements of a code. Once you understand the elements and how they come together to create the level, it can be a lot easier to select a code with confidence. In this article, we will focus on the documentation standards for evaluation and management codes: 

 

Chief Complaint

 

Every evaluation and management visit should start with a chief complaint - some kind of reason why the patient needs to be seen. Only a simple explanation is needed, it may be “cough” “1-year recheck of diabetes” or “nausea since Tuesday.” The chief complaint is required in order to establish medical necessity, a fundamental element of the Medicare program and a required element for billing this series of codes for the private sector as well. 

If you want to read the complete blog then click below: E/M Coding Basics for Internal Medicine